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CASE REPORT Open Access
Acute duodenal obstruction secondary tointussusception caused by
the duodenaldiverticulum: a case reportYuchen Guo, Bin Liu, Ziwen
Pan and Yang Zhang*
Abstract
Background: The duodenal intussusception is rarely reported and
usually occurs secondary to organic diseases ofthe duodenum such as
polyps, tumors and duplication cysts. Herein we report a case of
duodenal intussusceptioncaused by duodenal diverticulum.
Case presentation: A 21-year old male patient presented with
abdominal pain and vomiting for one day. Acontrast enhanced
computed tomography of the abdomen revealed duodenal
intussusception. On emergencylaparotomy, the intussusception had
reduced spontaneously while an invaginated diverticulum was seen at
thejunction of the descending and horizontal segments of the
duodenum. The diverticulum was resected and thepatient had
uneventful recovery.
Conclusion: Duodenal intussusception is a rare complication of
duodenal diverticulum. Being aware of thiscomplication of
diverticulum can help in timely diagnosis and treatment.
Keywords: Duodenal diverticulum, Intussusception, Endoscopy,
Duodenal obstruction, Case report
BackgroundIntussusception is characterized by telescoping of
theproximal bowel loop into the distal bowel. Primary idio-pathic
small bowel intussusception is common in chil-dren while secondary
intussusception is usually presentin adults with intestinal
diseases such as tumor, polyps,tubercles, adhesions and Meckel
diverticulum. However,the intussusception of duodenum is rarely
reported.Herein, we report a case of duodenal diverticulum
thatinvaginated in the duodenal lumen causing intussuscep-tion and
obstruction. Very few such cases have been re-ported in the English
literature [1].
Case presentationA 21-year old male presented with severe
intermittentabdominal pain, accompanied by vomiting for one
day.Physical examination was unremarkable. During the ad-mission,
he underwent contrast enhanced computedtomography (CT) of the
abdomen which revealed aduodeno-jejunal intussusception (Fig.
1a-c). Presence ofintestinal tumor or polyp could not be excluded.
Wecould not perform a gastroscopy because of the severesymptoms of
upper gastrointestinal obstruction of thispatient. So, decision to
perform exploratory laparotomywas taken. During the operation, the
horizontal and de-scending segments of the duodenum were found to
bedilated. However, no obvious intussusception or intes-tinal
lesion was observed during the operation. So, weperformed
intraoperative gastroscopy via oral route. Alarge diverticulum was
seen at the junction of the de-scending and horizontal segments of
the duodenum,which had invaginated into the lumen of the
duodenum
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* Correspondence: [email protected] of
Gastrointestinal Surgery, First Hospital of Jilin
University,Changchun 130021, Jilin, China
Guo et al. BMC Gastroenterology (2020) 20:234
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(Fig. 2). Considering it to the lead point of intussuscep-tion,
we planned the surgical excision of the diverticu-lum. We made
incision at the base of the diverticulum,resected the duodenal
diverticulum and sutured the duo-denal incision (Fig. 3). The
histopathological report ofthe resected specimen indicated presence
of submucosaledema, vasodilatation, congestion and hemorrhage.Acute
and chronic inflammatory cell infiltration was alsopresent (Fig.
4). The postoperative recovery was un-eventful with the
postoperative hospital stay of 8 days.At one-year follow-up, the
patient is symptom-free.
Discussion and conclusionsBowel intussusception is rare in
adults, accounting for5% of the intussusceptions in all age group
and 1–5%cases of bowel obstruction in adults [2]. Among
them,duodenal intussusception is extremely rare. Duodenal
in-tussusception can occur because of the excessive mobil-ity of
the duodenal wall in cases with intestinalmalrotation [3]. Duodenal
intussusception without
Fig. 1 a. The cross section of abdominal CT shows the
typicalbowel-within-bowel sign suggestive of duodenal
intussusceptioninto the jejunum (green circle). The intestinal wall
of the head wasthickened. The degree of strengthening was slightly
reduced. Lumpycontents can be seen in the duodenal cavity. b. The
coronal sectionof the CT scan shows the intussusception of duodenum
into thejejunum (green circle) and the descending part of duodenum
(bluecircle) c. The sagittal section of the CT scan shows
theintussusception (green circle) and its positional relation with
superiormesenteric artery (red arrow)
Fig. 2 A diverticulum was seen at the junction of the
descendingand horizontal segments of the duodenum, which had
turnedinward into the lumen of the duodenum (green arrow)
Guo et al. BMC Gastroenterology (2020) 20:234 Page 2 of 5
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intestinal malrotation is usually not seen due to therelatively
fixed retroperitoneal position of the duode-num. There are very few
reports of the duodenal in-tussusception caused by various factors
such asprolapse of duodenal tumors, ampullary lesions, du-plication
cysts, and congenital malrotation [3–6].However, in the present
case, duodenal intussuscep-tion occurred due to diverticulum. In
extreme cases,duodenal intussusception can lead to biliary
obstruc-tion [7, 8].
Duodenum is the second most frequent site in the di-gestive
tract for diverticular disease. Duodenal diverticu-lum mostly
occurs in the second or third portion of theduodenum along the
pancreatic or mesenteric border,and commonly near the ampulla of
Vater [9]. Duodenaldiverticula can be congenital or, more
frequently, an ac-quired pseudodiverticula. They are usually
asymptom-atic. Approximately 5% of them are associated
withcomplications, such as hemorrhage, obstruction, com-pression of
biliopancreatic structures, inflammation and
Fig. 3 Duodenal lumen was opened at the base of the
diverticulum. The diverticulum was turned inside out. The green
arrow indicates themucosal side of the diverticulum
Fig. 4 The histopathological examination of the resected
diverticulum revealed submucosal edema, vasodilatation, congestion
and hemorrhage.Additionally, acute and chronic inflammatory cell
infiltration was also seen
Guo et al. BMC Gastroenterology (2020) 20:234 Page 3 of 5
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perforation. In the current case, the duodenal diver-ticulum got
invaginated into the lumen of the duode-num and got pushed into the
proximal jejunum dueto intestinal peristalsis leading to
intussusception.However, we didn’t observe the intussusception
dur-ing the surgery due to spontaneous reduction, as re-ported in
previous cases [10, 11]. Duodenalintussusception is generally
transient and non-obstructive [11]. Sometimes the duodenal
intussuscep-tion may retrograde spontaneously because of thepoor
mobility of the duodenal wall [10].The clinical manifestations in
adults with duodenal
intussusception are usually non-specific and includenausea,
vomiting and epigastric pain [6]. AbdominalCT is a very sensitive
modality for diagnosis and canusually detect the lead point
responsible for intussus-ception if present. CT may reveal the
typical bowel-within-bowel sign. However, mucosal prolapse canmimic
these signs in the absence of intussusception[12]. Some cases of
duodenal intussusception havebeen reported, but it is unclear
whether thisphenomenon is true intussusception or simple muco-sal
prolapse, which is misinterpreted as intussuscep-tion [3, 13, 14].
However, in the present case, thediverticulum had invaginated into
the lumen of theduodenum, which acted as the lead point of the
in-tussusception. So, we believe that the present casedidn’t had
simple mucosal prolapse but intussuscep-tion. Endoscopy is another
useful imaging modalityfor the diagnosis of intussusception and its
lead pointif present. Additionally, it is useful in making
tissuediagnosis which helps in planning definitive treat-ment.
Also, endoscopy may help reduce the duodenalintussusception before
surgery. We believe that retro-grade traction may occur due to
gastric and proximalduodenal dilatation due to insufflation.
However, thishypothesis needs to be proven by future studies.
Themanagement of duodenal intussusception depends onthe underlying
cause and severity of symptoms. If thecause is malignancy then
pancreatoduodenectomy isrequired. It is a benign disease such as
adenoma orpolyp or diverticulum as seen in the present casethen
simple endoscopic or surgical excision of the le-sion is curative.
Some cases of intestinal malrotationprecipitating duodenal
intussusception may also re-quire surgical correction.Duodenal
intussusception secondary to duodenal di-
verticulum is rarely reported. Duodenal intussusceptionshould be
considered in patients with duodenal diver-ticulum having
persistent or recurrent abdominal symp-toms. Detailed
investigations should be performed tomake the correct diagnosis.
Endoscopy may help reducethe duodenal intussusception before
surgery due to gas-tric and proximal duodenal dilatation due to
insufflation.
However, this hypothesis needs to be proven by
futurestudies.
AbbreviationCT: Computed tomography
AcknowledgementsNo acknowledgements.
Authors’ contributionsYCG designed and drafted the work, and
substantively revised it. BL hasmade contributions to acquisition
of data and drafted the work. ZWP hasmade contributions to
acquisition of data and drafted the work. YZ hasmade contributions
to conception and design of the work, and substantivelyrevised it.
All authors have approved the submitted version (and
anysubstantially modified version that involves the author’s
contribution to thestudy). All authors have agreed both to be
personally accountable for theauthor’s own contributions and to
ensure that questions related to theaccuracy or integrity of any
part of the work, even ones in which the authorwas not personally
involved, are appropriately investigated, resolved, and
theresolution documented in the literature.
FundingNo funding was received.
Availability of data and materialsNot applicable.
Ethics approval and consent to participateEthical approval was
obtained from the Ethics Committee of First Hospital ofJilin
University.
Consent for publicationThe written consent to publish the
personal and clinical details (includingfigures) of the participant
was obtained from study participant.
Competing interestsThere are no competing interests.
Received: 14 March 2020 Accepted: 12 July 2020
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AbstractBackgroundCase presentationConclusion
BackgroundCase presentationDiscussion and
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contributionsFundingAvailability of data and materialsEthics
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interestsReferencesPublisher’s Note